Soldiers deployed as part of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) are experiencing a variety of injuries that have long-term implications for their health and well-being and represent significant challenges for the Veterans Health Administration (VHA). American military personnel who have served in Afghanistan and Iraq are experiencing long periods of extreme stress, intense battlefield experiences that pose threats of personal harm and death, taking life, and witnessing or experiencing injuries and death that can have an impact on mental health and emotional wellbeing. Research has shown that combat experience and the stress associated with deployment increase the risk of developing mental health difficulties, including posttraumatic stress disorder (PTSD), depression, and substance abuse [1-2]. The estimated lifetime prevalence of PTSD is 30.9 percent for male Vietnam veterans and 26.9 percent for female veterans who served in the Vietnam war.
Elevated rates of PTSD and other Diagnostic and Statistical Manual of Mental Disorders Axis I diagnoses have been reported among OIF/OEF veterans. PTSD is the most common mental health diagnosis among veterans returning from combat and the second most frequent medical diagnosis among veterans who have used VHA healthcare services [1,3]. Soldiers who have sustained a combat injury are at particular risk for PTSD [4-9]. Emerging evidence also suggests considerable impact on families of men and women deployed in OIF/OEF. Although widespread recognition is found among the research and clinical communities concerning the hardships that families face in general, research has largely been based on studies of nonmilitary/nonveteran participants, such as older adults, and condition-specific groups, such as those with dementia or stroke [10-12]. Less is known about the physical and emotional stress experienced by spouses of veterans with PTSD (http://www.ncptsd.va. gov/ncmain/ncdocs/fact_shts/fs_partners_veterans.html, last accessed March 23, 2009) .
We describe our efforts to identify domains and measures for inclusion in a battery of assessment tools to examine the well-being of spouses assisting with veterans' care. Domains identified to assess spousal wellbeing include health status, mental health, alcohol and substance abuse, conflict, and marital satisfaction. This study was part of a larger research agenda designed to understand veteran and spousal characteristics and mediating variables that inform spouses' response(s) or appraisal of caregiving and, ultimately, veterans' outcomes. The conceptual framework (Figure) guiding our work, including identification of domains relevant to spousal well-being, is adapted from stress and coping models [14-15]. That providing care to a family member or friend often leads to increased strain and/or burden is widely accepted. The inability to cope effectively with the stressors associated with caregiving can negatively impinge on the spouses' (and veterans') mental and physical health. Changes in care responsibilities and relationships can lead to increased burden and strain that may or may not be successfully managed [16-17].
Recent work in the area of caregiver identity theory suggests that caregivers experience distress in response to a disruption in the identity maintenance process . The caregiver typically assimilates caregiving into the spousal relationship with little or no distress when the need for caregiving/family assistance is minimal. This process stretches but does not threaten the caregiver's existing identity. However, when the need for assistance requires a fundamental change in spousal roles, threats to a person's existing identity are dramatic and significant effort is required to accommodate the changes. If the need for assistance occurs suddenly or intensifies, the added responsibilities typically surpass the activities that generally characterize the spousal role, and this creates a discrepancy between the spouse's helping actions and how self-identity is perceived in relation to the marriage. …